Hospital Beds Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for hospital beds HCPCS codes E0260, E0261, and E0303 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 13.80%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. | 44.74% |
2. | The documentation does not have a valid Standard Written Order (SWO). | 13.16% |
3. | The SWO is missing a description of the item. | 7.89% |
4. | The treating practitioner's order, supplier prepared statement, or the practitioner's attestation, by itself, does not show enough documentation of medical necessity. | 7.89% |
5. | The documentation is incomplete. | 5.26% |
6. | We did not receive any medical record documentation. | 5.26% |
7. | Medical records do not support that the beneficiary needs frequent changes in body position and/or has an immediate need for a change in body position. | 5.26% |
8. | Medical records do not support that the beneficiary meets one of the four criteria for a fixed height hospital bed. | 5.26% |
9. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 2.63% |
10. | The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary. | 2.63% |
*The total percentage will be greater than 100% because some claims denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Hospital Beds & Accessories – LCD (L33820)
- Hospital Beds & Accessories – Policy Article (A52508)
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: May 21, 2024